Background: Previous studies applying Sepsis-3 criteria to pediatric sepsis were based on retrospective analyses of pediatric intensive care unit (PICU) cohorts not designed to investigate sepsis and included children without microbiologically defined infections. We aimed to validate organ dysfunction criteria in a prospective cohort of children with blood culture-proven sepsis, including emergency department, PICU, and ward patients.
Methods: Between 1.9.2011 and 31.12.2015, this multi-center prospective population-based cohort study recruited children < 17 years with blood culture-proven sepsis defined according to 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria. We excluded prematurely born infants and term born infants aged ≤ 7 days. We compared the performance of 2005 IPSCC, Pediatric Logistic Organ Dysfunction (PELOD)-2, and pediatric Sequential Organ Failure Assessment (pSOFA) score on the day of blood culture sampling to identify children who died ≤ 30 days after sepsis onset using ROC curves. To adjust 2005 IPSCC, PELOD-2, and pSOFA for age, sex, and presence of chronic medical conditions, we fitted logistic mixed-models.
Results: We analyzed 878 sepsis episodes in 807 children. In 288 (33%) episodes an organ dysfunction was present. Thirty-eight (4%) children died within 30 days after sepsis onset. Case fatality ratio was 1% in children without organ dysfunction, 5% in children with a single organ dysfunction, and 21% in children with multi organ dysfunction. The AUC to discriminate sepsis episodes with fatal outcome was 0.82 (95% CI 0.74 - 0.90) for 2005 IPSCC, 0.73 (0.63 - 0.83) for PELOD-2, and 0.78 (0.69 - 0.88) for pSOFA, with adjusted AUCs of 0.87 (0.82 - 0.92), 0.83 (0.76 - 0.89), and 0.85 (0.78 - 0.92). Cardiac, respiratory, and neurological dysfunction were the most relevant organ dysfunctions in our population. Considering only these three organs AUCs were 0.78 (0.70 - 0.87) for 2005 IPSCC, 0.72 (0.62 - 0.82) for PELOD-2, and 0.76 (0.66 - 0.86) for pSOFA, with adjusted AUCs of 0.9 (0.85 - 0.94) for 2005 IPSCC, 0.87 (0.82 - 0.93) for PELOD-2, and 0.88 (0.82 - 0.94) for pSFOA.
Conclusions: Different measures of pediatric organ dysfunction performed comparably, which can inform the revision of pediatric sepsis definitions. While presence of any organ failure increased the risk of death in pediatric sepsis, cardiac, pulmonary, and neurological dysfunction were most important with respect to death.
Acetate versus Lactate buffered balanced Infusates on Hemodynamic Stability in Patients undergoing Cardiac Surgery – a randomized controlled double-blind Trial
Introduction: Recent evidence suggests that acetate-buffered infusions result in better hemodynamic stabilization than 0.9% saline in patients undergoing major surgery. The choice of buffer in balanced crystalloid solutions may modify their hemodynamic effects. We therefore compared the inopressor requirements of Ringer’s acetate and lactate for perioperative fluid management in patients undergoing cardiac surgery.
Methods: Using a randomized controlled double blind design, we compared acetated Ringer’s (RA) to lactated Ringer’s (RL) with respect to the cumulative dose of inopressors administered until postoperative hemodynamic stabilization. Secondary outcomes were the duration of inopressor administration, the total fluid volume administered, and changes in acid-base homeostasis. Patients undergoing elective valvular +/- bypass surgery were included. Patients with severe cardiac (EF< 30%), renal (eGFR< 30ml/min/1.73m2), liver dysfunction (bilirubin >3mg/dl), florid endocarditis or chronic inflammatory disease were excluded from the analysis.
Results: Seventy-five patients were randomly allocated to the RA arm, 73 to RL. The hemodynamic profiles were comparable between the groups. The groups did not differ with respect to the average rate of inopressors (RA 2.1 mcg/kg/h, IQR 0.5-8.1 vs. RL 1.7 mcg/kg/h, IQR 0.7-8.2, p=0.989). Cumulative doses of inopressors and time on individual and combined inopressors did not differ between the groups. Sensitivity analysis showed that patients in the RL-group received a significantly higher dose of epinephrine per hour of epinephrine when compared to the RA-group (median 4.5 µg/kg/h, IQR 0.4-33.0 vs. median 0.2 µg/kg/h, IQR 0.1-9.3, p=0.047). If considered only for the period in the ICU, more patients in the lactated Ringer’s group received epinephrine infusions (14 (19.2%) vs. 6 (8.0%), p=0.047). No differences were found in acid-base parameters and their evolution over time.
Conclusions: In this study, acetate-buffered and lactated-buffered infusion solutions are equal for early hemodynamic stabilization in patients undergoing cardiac surgery and the evolution of acid-base parameters was similar.
Complications of regional citrate anti-coagulation for CRRT: An observational study
Context and Aims
Regional citrate anticoagulation (RCA) has been recommended as the default anticoagulation modality for continuous renal replacement therapy (CRRT). It was associated with a low rate of complications in randomized controlled trials. However, little is known about the incidence of such complications in real life. In our institution, CRRT is applied either as continuous veno-venous hemodialysis (CVVHD) with RCA (default modality) or as continuous veno-venous hemofiltration (CVVH) with heparin anticoagulation (in case of RCA contra-indications).
Hence, we sought to retrospectively evaluate the type and rate of complications associated with CRRT according to the type CRRT modality used.
We retrospectively identified all patients who received CRRT in our institution between January and December 2016. In those patients, using scanned medical records, we reviewed each CRRT session and determined circuit duration as well as therapy associated complications. For this purpose, we recorded, the highest and lowest level of the following variables: pH, base excess, sodium, ionized calcium, platelets and body temperature. Only new alterations (not present at the time of circuit initiation) were considered. Medical records were also screened for other complications potentially attributable to the therapy. The incidence of such parameters were compared according to whether the circuit was run in CVVHD-RCA or CVVH-Heparin mode.
We analyzed 636 CRRT sessions in 121 patients. Of those 385 (60.5%) were performed in CVVHD-RCA mode and 251 (39.5%) in CVVH-Heparin mode. Compared with CVVH-Heparin mode, CVVHD-RCA mode was associated with a longer circuit lifespan (median duration 54.9 (IQR 44.6) vs 15.3 hours (IQR 22.4, p < 0.0001), a higher rate of metabolic acidosis (77 (20.2%) vs 18 (7.2%) (p < 0.0001), and of metabolic alkalosis (186 (48.7%) vs 43 (17.1%), (p=0.0001) as well as mild hypocalcemia (96 (25.1%) vs 26 (10.8%), p < 0.0001). The majority of these alterations were mild and of unknown clinical significance. Only one possible citrate intoxication was observed. There was no difference in the rate of other CRRT associated complications.
CVVHD-RCA was associated with a much longer circuit life and with an increased rate of minor metabolic complications, in particular acid-base derangements. CVVHD-RCA appears safe in patients without contra-indications but requires the application of a strict protocol.
ADEQUACY OF STRESS ULCER PROPHYLAXIS PRESCRIPTION IN ICU: AN OBSERVATIONAL STUDY
Background & Aims: The Swiss Society of Intensive Medicine, as part of its "Choosing wisely" campaign, has recently recommended to assess the adequacy of stress ulcer prophylaxis (SUP) among other common practices in intensive medicine. Indeed, SUP prescription might not be sufficiently challenged throughout patients' stay in the intensive care unit (ICU) and might erroneously be maintained on ICU or even hospital discharge. The aims of this study are: 1. To describe the frequency of SUP prescription in our unit and to determine its adequacy with local guidelines 2. To determine the proportion of patients still receiving SUP on ICU and hospital discharge in the absence of a new indication for acid-suppressive therapy.
Methods: This is a retrospective study conducted in the 35-beds adult medico-surgical ICU of a tertiary care center. Medical records of all patients admitted between October 1st and November 30th 2017 were screened. Patients with an ICU length of stay shorter than 24 hours, with prior indication for acid-suppressive therapy or admitted for a gastrointestinal bleeding were excluded. SUP prescription's adequacy was assessed on a day-to-day basis, according to our local guidelines. We then assessed the continuation of SUP on ICU and hospital discharge and considered any new indication(s) for acid-suppressive therapy.
Results: Among the 372 patients admitted during the study period, 140 (855 patient days (PD)) fulfilled inclusion criteria. Among them 130 (92.9%) received SUP during their ICU stay corresponding to 796 (93.1%) PD). SUP consisted in esomeprazole in 686 (86.2%) PD. Overall, the SUP was inadequate in 558 (65.3%) PD: prescribed while not indicated in 543 (63.5%) or not prescribed while indicated in 15 (1.8%). On ICU discharge, SUP prescription was maintained in 58 (44.6%) patients of which 8 had a new indication for acid-suppressive therapy. Similarly, SUP was maintained on hospital discharge in 39 (67%) patients of which 11 had a new indication for acid-suppressive therapy. Hence, SUP was inadequately maintained in 38% of patients on ICU discharge and 21% on hospital discharge.
Conclusions: SUP was inappropriate (not indicated or forgotten) in almost two thirds of ICU patient-days. Moreover this prescription was erroneously maintained in a very large number of patients both on ICU and hospital discharge. SUP guidelines and the need for a daily reevaluation in particular on ICU discharge should be reminded to prescribers.
Information conveyed by electrical diaphragmatic activity during unstressed, stressed and assisted spontaneous breathing: a physiologic study.
Background: The electrical activity of the crural diaphragm (Eadi), a surrogate of respiratory drive, can now be measured at the bedside in mechanically ventilated patients with a specific catheter. The expected range of Eadi values under stressed or assisted spontaneous breathing is unknown. This study explored Eadi values in healthy subjects during unstressed (baseline), stressed (with a resistance) and assisted spontaneous breathing. Relation between Eadi and inspiratory effort was analyzed.
Methods: Thirteen healthy male volunteers were included in this randomized crossover study. Eadi and esophageal pressure (Peso) were recorded during unstressed and stressed spontaneous breathing and under assisted ventilation delivered in pressure support (PS) at low and high assist level and in neurally adjusted ventilatory assist (NAVA). Peak, mean and integral of Eadi, breathing pattern, esophageal pressure-time product (PTPeso) and work of breathing (WOB) were calculated offline.
Results: Median [interquartile range] peak Eadi at baseline was 17 [13-22] μV and was above 10 μV in 92% of the cases. Eadi max defined as Eadi measured at maximal inspiratory capacity reached 90 [63 to 99] μV. Median peak Eadi/Eadi max ratio was 16.8 [15.6-27.9] %. Compared to baseline, respiratory rate and minute ventilation were decreased during stressed non assisted breathing whereas peak Eadi and PTPeso were increased. During unstressed assisted breathing, peak Eadi decreased during high level PS compared to unstressed non-assisted breathing and to NAVA (p = 0.047). During stressed breathing, peak Eadi was lower during all assisted ventilation modalities compared to stressed non-assisted breathing. During assisted ventilation, across the different conditions, peak Eadi changed significantly whereas PTPeso and WOB/minute were not significantly modified. Finally, Eadi signal was still present even when Peso signal was suppressed due to high assist levels.
Conclusion: Eadi analysis provides complementary information compared to respiratory pattern and to Peso monitoring, particularly in presence of high assist levels.